The Journal of Laryngology and Otology December 1990, Vol. 104, pp. 965-967
Enlarged adenoid and adenoidectomy in adults: Endoscopic approach and histopathological study REDA H. KAMEL, M.D.*, ELIA A. ISHAK, PH.D.t (Cairo, Eygpt)
Abstract
Adenoid enlargement is uncommon in adults and because examination of the nasopharynx by indirect posterior rhinoscopy is inadequate, many cases of enlarged adenoid in adults are misdiagnosed and accordingly maltreated. This study was conducted on 35 cases of enlarged adenoid aged between 20 and 42 years. The nasal endos.cope was utilized to identify the adenoid mass. Adenoidectomy under transnasal endoscopic control was performed and all the excised material was sent for histopathological examination. Adenoidectomy resulted in marked improvement in 94 per cent of cases without major complications. Histopathological examination revealed non-specific inflammatory reaction in 15 cases (43 per cent), pure reactive changes, predominantly follicular hyperplasia, in two cases (6 per cent) and mixed pattern in 18 cases (51 per cent). Endoscopic follow-up for an average 17 months identified recurrence in only two patients. It was concluded that enlarged adenoid tissue in adults has some histopathological differences from that in children and adenoidectomy under transnasal endoscopic control is safe and reliable.
24 cases, nasal obstruction 18 cases, rhinorrhoea eight cases, nasal tone six cases and/or snoring four cases. The duration of these symptoms ranged between two and 13 years with an average of 5.5 years. Many cases had undergone unsuccessful attempts at medical and surgical management. All of the cases reported previous medical treatments in the form of antibiotics, antihistamines, decongestants (local or systemic) and/or corticosteriod (local or systemic). Eleven cases had a history of previous nasal surgery once or more in the form of inferior meatal antrostomy, radical antrum operation, inferior turbinate cauterization or resection and/or septal surgery. The 30°, 4 mm nasal endoscope was utilized to identify the nasopharyngeal mass. The mass had either a smooth, (22 cases) or an irregular surface, (13 cases). In eight cases inspissated pus was exiting through the surface of the mass. The origin of the mass was from the vault and/or posterior wall of the nasopharynx. Profuse retained secretions were found in front of the adenoid mass at the posterior aspect of the inferior meatus and nasal cavity in 28 cases. Associated chronic sinusitis was detected in three cases and bilateral secretory otitis media was identified in five. Repeated biopsies of these masses excluded malignancy and revealed chronic nonspecific inflammation with or without reactive lymphoid hyperplasia. Adenoidectomy was performed under general anaesthesia. The main bulk of the mass was removed using a large adenoid curette. Removal of the mass was completed under transnasal endoscopic control using the
Introduction
The presence of a nasopharyngeal mass in an adult associated with aural problems usually arouses the suspicion of nasopharyngeal carcinoma (Maves, 1986). During the last three years of endoscopic research work, we identified many adults with nasopharyngeal mass whose repeated biopsies excluded malignancy and revealed non-specific inflammation with or without reactive follicular hyperplasia. The diagnosis of chronic adenoiditis was postulated and adenoidectomy was performed. Adenoid enlargement occurs most commonly between the age of three and seven years. Atrophy usually begins after 10 years of age and is complete before the age of 20 (Gray, 1977; Maves, 1986; Hibbert, 1987; Fujiyoshi et al., 1989). However, a few authors stated that persistence of adenoid in adult life is not uncommon (Cowan, 1982) and the nasopharyngeal lymphoid tissue can occasionally undergo prominent or even marked hyperplasia in adults (Theobald, 1948; Haffner, 1987). The aim of this work was to discuss the adenoid in adults as a clinical and a pathological entity and to evaluate the procedure of adenoidectomy under transnasal endoscopic control in adults. Material and methods
This study was conducted on 35 cases of enlarged adenoid aged between 20 and 42 years with an average of 29 years. There were 19 males and 16 females. The main symptoms were postnasal discharge 32 cases, headache
"Lecturer of Otolaryngology, Head and Neck Surgery, Cairo University, Egypt, tAssistant Professor of Pathology, Cairo University, Egypt. Accepted for publication: 10 October 1990. 965
966
R. H. KAMEL, E. A. ISHAK
TABLE I PRE-OPERATIVE INCIDENCE, POST-OPERATIVE IMPROVEMENT AND PERCENTAGE OF IMPROVEMENT OF SYMPTOMS IN THE 3 5 CASES OF ENLARGED ADENOID IN ADULTS
Percentage of Pre-operative Post-operative post-operative incidence* improvement* improvement % Post-nasal drip Headache Nasal obstruction Rhinorrhoea Nasal tone Snoring
32 24 18 8 6 4
29 22 18 7 6 4
91 92 100 87 100 100
T h e total number of patients was 35.
forward cutting forceps transnasally or the upward cutting forceps transorally. A pack was left in the nasopharynx for 10 minutes and then removed. Bleeding was secured utilizing an insulated suction tip for cauterization. The nasal endoscope helped ensure complete excision of the mass, avoid injury to the eustachian tube and control bleeding. The patients were discharged on the next day and given a course of an antibiotic for one week. All the excised material was fixed in neutral formalin 10 per cent and processed routinely. Serial sections 5 \i thick were prepared and stained by Haematoxylin and Eosin.
Results During adenoidectomy in the 35 adult cases, there was no need for intra-operative blood transfusion or posterior nasal packing and post-operatively none of the patients suffered from remarkable bleeding or longterm regurgitation or nasal tone. During the first postoperative week there were mild dysphagia, local pain, referred otalgia and minimal blood tinged spitting. Endoscopic follow-up of these cases for periods ranging between 12 and 24 months (average 17 months) only showed recurrence in two patients. In these two cases some enlarged lymphoid follicles were identified on the posterior pharyngeal wall oozing pus causing local irritation and post-nasal discharge. They required revision surgery. Associated sinusitis improved in the three cases and aural ventilation improved in four cases and only one case required ventilation tubes. Subjectively, there was improvement in all of the pre-operative symptoms (Table I) and 13 cases became asymptomatic, 20 cases improved and two cases failed to show any improvement. The pathological findings showed a non-specific inflammatory reaction in 15 cases, reactive changes, predominantly follicular hyperplasia, in two cases and a non-specific inflammatory with superadded reactive follicular hyperplasia, in 18 cases. The covering epithelium was respiratory, pseudostratified squamous or metaplastic. The epithelium was mostly intact with very few foci
FIG. 1 Histopathological section of the adenoid mass in adult showing polypoid surface with squamous covering, overlying chronic non-specific inflammation with dilated glands showing retained mucous entangling inflammatory cells (H & E x 90).
967
ENLARGED ADENOID AND ADENOIDECTOMY IN ADULTS
showing superficial erosion. One case revealed prominent attempts at papillary proliferation. There was no evidence of any dysplastic changes (Fig. 1).
Discussion
The failure to diagnose enlarged adenoid in adults is most commonly due to the unfamiliarity of this disease in adulthood and the inadequate examination of the nasopharynx by indirect posterior rhinoscopy. This study shows that enlarged nasopharyngeal tonsils in adults has some differences from that in children. Macroscopically the mass had a smooth (63 per cent) or an irregular surface (37 per cent) and none showed crypts or vertical furrows like those of children. It was previously stated that histological studies of the adenoidal tissue in children showed hyperplasia of lymphoid follicles and very rarely showed septic foci or microabscess and the existence of chronic adenoiditis as a term was denied (Maves, 1986; Michaels, 1987; Fujiyoshi, et al, 1989). However, the main bulk of the adenoidal tissue in our study was attributed to chronic inflammatory reaction, fibrosis and retention cysts which could be grouped histopathologically under the title of chronic hypertrophic nasopharyngitis or chronic adenoiditis. There is a controversy concerning the aetiology of enlargement of the nasopharyngeal tonsils in adults. It is most probably multifactorial and due to infection (bacterial or viral) with reactive immunological hyperplastic changes related to the infection and/or external irritants (e.g. dust and smoking). The inhaled air stream, after passing through the narrow nasal cavity, is suddenly released and changes its direction downwards. As a result, the speed of the air stream becomes slower and the dust, bacilli or poisonous gases adhere or stimulate the nasopharyngeal wall more easily (Horiguti and Yasuo, 1973). Although some investigators attributed the enlargement of the nasopharyngeal tonsil to allergic disorders (Gray, 1977; Hibbert, 1987), others denied any significant role of the nasopharyngeal tonsil in allergic reactions (Raphael and Kaliner, 1987). However, recently, adenoidal enlargement was reported in HIVinfected patients (Fairley, etal, 1988). From this study it was concluded that: 1. Enlarged adenoid in adults has some macroscopic and microscopic differences from that in children. Histopathologically it could be termed chronic
hypertrophic nasopharyngitis or chronic adenoiditis. 2. Enlarged adenoid in adults should be considered in the differential diagnosis of cases suffering from nasal obstruction, discharge, and headache or presenting by a nasopharyngeal mass with aural problems. 3. Adenoidectomy in adults is safe and reliable. The nasal endoscope helps remove the adenoid completely with good hemostasis and no injury to the eustachian tube. Acknowledgement
Telescopes, instruments and photodocumentation equipment for this study were provided by Karl Storz. References
Cowan, D. L. (1982): In Logan Turner's Diseases of the Nose, Throat and Ear. (Birrel, J. F., ed.), 9th edn., Wright. PSG: Bristol, p. 129-139. Fairley, J. W., Dhillon, R. S., Weller, I. V. (1988): HIV, glue ear and adenoidal hypertrophy. Lancet, 2: 1422. Fujiyoshi, T., Watanbe, T., Ichimiya, I., Mogi, G. (1989): Functional architecture of the nasopharyngeal tonsil. American Journal of Otolaryngology, 10: 124-131. Gray, L. P. (1977): The T's and A's problem—Assessment and reassessment. Journal of Laryngology and Otology, 91: 11-32. Haffner, D. K. (1987): Pathology of the tonsils and adenoids. Otolaryngologic Clinics of North America, 20, 2: 279-286. Hibbert, J. (1987): In Scott-Brown's Otolaryngology. (Evans, J. N. G. and Kerr, A. G. eds.), 5th edn., Vol. 6, Butterworth: London, Boston, p 368-383. Horiguti, S., Yasuo, I. (1973): Headache with particular relationship to nasopharyngitis. Bulletin of Tokyo Medical and Dental University, 20: 173-192. Maves, M. D. (1986): In Otolaryngology Head and Neck Surgery. (Cummings, C. W. and Schuller, D. E., eds.), Vol. 2, The C. V. Mosby Company; St. Louis, Toronto, p 1117-1127. Michaels, L. (1987): In Ear, Nose and Throat Histopathology, Springer-Verlag: London, Berlin, Heidelberg, New York, p239-243. Raphael, G., Kaliner, M. (1987): Allergy and the pharyngeal lymphoid tissue. Otolaryngologic Clinics of North America, 20, 2: 295-304. Theobald, W. H. (1948): Associated symptomatology of diseases of the epipharynx. Journal of Laryngology and Otology, 57: 677-685. Address for correspondence: Dr. RedaKamel, M.D., Flat 6, 5 Dokky Street, Dokky-12311, Giza, Cairo, Egypt.
Enlarged adenoid and adenoidectomy in adults: Endoscopic approach and histopathological study REDA H. KAMEL, M.D.*, ELIA A. ISHAK, PH.D.t (Cairo, Eygpt)
Abstract
Adenoid enlargement is uncommon in adults and because examination of the nasopharynx by indirect posterior rhinoscopy is inadequate, many cases of enlarged adenoid in adults are misdiagnosed and accordingly maltreated. This study was conducted on 35 cases of enlarged adenoid aged between 20 and 42 years. The nasal endos.cope was utilized to identify the adenoid mass. Adenoidectomy under transnasal endoscopic control was performed and all the excised material was sent for histopathological examination. Adenoidectomy resulted in marked improvement in 94 per cent of cases without major complications. Histopathological examination revealed non-specific inflammatory reaction in 15 cases (43 per cent), pure reactive changes, predominantly follicular hyperplasia, in two cases (6 per cent) and mixed pattern in 18 cases (51 per cent). Endoscopic follow-up for an average 17 months identified recurrence in only two patients. It was concluded that enlarged adenoid tissue in adults has some histopathological differences from that in children and adenoidectomy under transnasal endoscopic control is safe and reliable.
24 cases, nasal obstruction 18 cases, rhinorrhoea eight cases, nasal tone six cases and/or snoring four cases. The duration of these symptoms ranged between two and 13 years with an average of 5.5 years. Many cases had undergone unsuccessful attempts at medical and surgical management. All of the cases reported previous medical treatments in the form of antibiotics, antihistamines, decongestants (local or systemic) and/or corticosteriod (local or systemic). Eleven cases had a history of previous nasal surgery once or more in the form of inferior meatal antrostomy, radical antrum operation, inferior turbinate cauterization or resection and/or septal surgery. The 30°, 4 mm nasal endoscope was utilized to identify the nasopharyngeal mass. The mass had either a smooth, (22 cases) or an irregular surface, (13 cases). In eight cases inspissated pus was exiting through the surface of the mass. The origin of the mass was from the vault and/or posterior wall of the nasopharynx. Profuse retained secretions were found in front of the adenoid mass at the posterior aspect of the inferior meatus and nasal cavity in 28 cases. Associated chronic sinusitis was detected in three cases and bilateral secretory otitis media was identified in five. Repeated biopsies of these masses excluded malignancy and revealed chronic nonspecific inflammation with or without reactive lymphoid hyperplasia. Adenoidectomy was performed under general anaesthesia. The main bulk of the mass was removed using a large adenoid curette. Removal of the mass was completed under transnasal endoscopic control using the
Introduction
The presence of a nasopharyngeal mass in an adult associated with aural problems usually arouses the suspicion of nasopharyngeal carcinoma (Maves, 1986). During the last three years of endoscopic research work, we identified many adults with nasopharyngeal mass whose repeated biopsies excluded malignancy and revealed non-specific inflammation with or without reactive follicular hyperplasia. The diagnosis of chronic adenoiditis was postulated and adenoidectomy was performed. Adenoid enlargement occurs most commonly between the age of three and seven years. Atrophy usually begins after 10 years of age and is complete before the age of 20 (Gray, 1977; Maves, 1986; Hibbert, 1987; Fujiyoshi et al., 1989). However, a few authors stated that persistence of adenoid in adult life is not uncommon (Cowan, 1982) and the nasopharyngeal lymphoid tissue can occasionally undergo prominent or even marked hyperplasia in adults (Theobald, 1948; Haffner, 1987). The aim of this work was to discuss the adenoid in adults as a clinical and a pathological entity and to evaluate the procedure of adenoidectomy under transnasal endoscopic control in adults. Material and methods
This study was conducted on 35 cases of enlarged adenoid aged between 20 and 42 years with an average of 29 years. There were 19 males and 16 females. The main symptoms were postnasal discharge 32 cases, headache
"Lecturer of Otolaryngology, Head and Neck Surgery, Cairo University, Egypt, tAssistant Professor of Pathology, Cairo University, Egypt. Accepted for publication: 10 October 1990. 965
966
R. H. KAMEL, E. A. ISHAK
TABLE I PRE-OPERATIVE INCIDENCE, POST-OPERATIVE IMPROVEMENT AND PERCENTAGE OF IMPROVEMENT OF SYMPTOMS IN THE 3 5 CASES OF ENLARGED ADENOID IN ADULTS
Percentage of Pre-operative Post-operative post-operative incidence* improvement* improvement % Post-nasal drip Headache Nasal obstruction Rhinorrhoea Nasal tone Snoring
32 24 18 8 6 4
29 22 18 7 6 4
91 92 100 87 100 100
T h e total number of patients was 35.
forward cutting forceps transnasally or the upward cutting forceps transorally. A pack was left in the nasopharynx for 10 minutes and then removed. Bleeding was secured utilizing an insulated suction tip for cauterization. The nasal endoscope helped ensure complete excision of the mass, avoid injury to the eustachian tube and control bleeding. The patients were discharged on the next day and given a course of an antibiotic for one week. All the excised material was fixed in neutral formalin 10 per cent and processed routinely. Serial sections 5 \i thick were prepared and stained by Haematoxylin and Eosin.
Results During adenoidectomy in the 35 adult cases, there was no need for intra-operative blood transfusion or posterior nasal packing and post-operatively none of the patients suffered from remarkable bleeding or longterm regurgitation or nasal tone. During the first postoperative week there were mild dysphagia, local pain, referred otalgia and minimal blood tinged spitting. Endoscopic follow-up of these cases for periods ranging between 12 and 24 months (average 17 months) only showed recurrence in two patients. In these two cases some enlarged lymphoid follicles were identified on the posterior pharyngeal wall oozing pus causing local irritation and post-nasal discharge. They required revision surgery. Associated sinusitis improved in the three cases and aural ventilation improved in four cases and only one case required ventilation tubes. Subjectively, there was improvement in all of the pre-operative symptoms (Table I) and 13 cases became asymptomatic, 20 cases improved and two cases failed to show any improvement. The pathological findings showed a non-specific inflammatory reaction in 15 cases, reactive changes, predominantly follicular hyperplasia, in two cases and a non-specific inflammatory with superadded reactive follicular hyperplasia, in 18 cases. The covering epithelium was respiratory, pseudostratified squamous or metaplastic. The epithelium was mostly intact with very few foci
FIG. 1 Histopathological section of the adenoid mass in adult showing polypoid surface with squamous covering, overlying chronic non-specific inflammation with dilated glands showing retained mucous entangling inflammatory cells (H & E x 90).
967
ENLARGED ADENOID AND ADENOIDECTOMY IN ADULTS
showing superficial erosion. One case revealed prominent attempts at papillary proliferation. There was no evidence of any dysplastic changes (Fig. 1).
Discussion
The failure to diagnose enlarged adenoid in adults is most commonly due to the unfamiliarity of this disease in adulthood and the inadequate examination of the nasopharynx by indirect posterior rhinoscopy. This study shows that enlarged nasopharyngeal tonsils in adults has some differences from that in children. Macroscopically the mass had a smooth (63 per cent) or an irregular surface (37 per cent) and none showed crypts or vertical furrows like those of children. It was previously stated that histological studies of the adenoidal tissue in children showed hyperplasia of lymphoid follicles and very rarely showed septic foci or microabscess and the existence of chronic adenoiditis as a term was denied (Maves, 1986; Michaels, 1987; Fujiyoshi, et al, 1989). However, the main bulk of the adenoidal tissue in our study was attributed to chronic inflammatory reaction, fibrosis and retention cysts which could be grouped histopathologically under the title of chronic hypertrophic nasopharyngitis or chronic adenoiditis. There is a controversy concerning the aetiology of enlargement of the nasopharyngeal tonsils in adults. It is most probably multifactorial and due to infection (bacterial or viral) with reactive immunological hyperplastic changes related to the infection and/or external irritants (e.g. dust and smoking). The inhaled air stream, after passing through the narrow nasal cavity, is suddenly released and changes its direction downwards. As a result, the speed of the air stream becomes slower and the dust, bacilli or poisonous gases adhere or stimulate the nasopharyngeal wall more easily (Horiguti and Yasuo, 1973). Although some investigators attributed the enlargement of the nasopharyngeal tonsil to allergic disorders (Gray, 1977; Hibbert, 1987), others denied any significant role of the nasopharyngeal tonsil in allergic reactions (Raphael and Kaliner, 1987). However, recently, adenoidal enlargement was reported in HIVinfected patients (Fairley, etal, 1988). From this study it was concluded that: 1. Enlarged adenoid in adults has some macroscopic and microscopic differences from that in children. Histopathologically it could be termed chronic
hypertrophic nasopharyngitis or chronic adenoiditis. 2. Enlarged adenoid in adults should be considered in the differential diagnosis of cases suffering from nasal obstruction, discharge, and headache or presenting by a nasopharyngeal mass with aural problems. 3. Adenoidectomy in adults is safe and reliable. The nasal endoscope helps remove the adenoid completely with good hemostasis and no injury to the eustachian tube. Acknowledgement
Telescopes, instruments and photodocumentation equipment for this study were provided by Karl Storz. References
Cowan, D. L. (1982): In Logan Turner's Diseases of the Nose, Throat and Ear. (Birrel, J. F., ed.), 9th edn., Wright. PSG: Bristol, p. 129-139. Fairley, J. W., Dhillon, R. S., Weller, I. V. (1988): HIV, glue ear and adenoidal hypertrophy. Lancet, 2: 1422. Fujiyoshi, T., Watanbe, T., Ichimiya, I., Mogi, G. (1989): Functional architecture of the nasopharyngeal tonsil. American Journal of Otolaryngology, 10: 124-131. Gray, L. P. (1977): The T's and A's problem—Assessment and reassessment. Journal of Laryngology and Otology, 91: 11-32. Haffner, D. K. (1987): Pathology of the tonsils and adenoids. Otolaryngologic Clinics of North America, 20, 2: 279-286. Hibbert, J. (1987): In Scott-Brown's Otolaryngology. (Evans, J. N. G. and Kerr, A. G. eds.), 5th edn., Vol. 6, Butterworth: London, Boston, p 368-383. Horiguti, S., Yasuo, I. (1973): Headache with particular relationship to nasopharyngitis. Bulletin of Tokyo Medical and Dental University, 20: 173-192. Maves, M. D. (1986): In Otolaryngology Head and Neck Surgery. (Cummings, C. W. and Schuller, D. E., eds.), Vol. 2, The C. V. Mosby Company; St. Louis, Toronto, p 1117-1127. Michaels, L. (1987): In Ear, Nose and Throat Histopathology, Springer-Verlag: London, Berlin, Heidelberg, New York, p239-243. Raphael, G., Kaliner, M. (1987): Allergy and the pharyngeal lymphoid tissue. Otolaryngologic Clinics of North America, 20, 2: 295-304. Theobald, W. H. (1948): Associated symptomatology of diseases of the epipharynx. Journal of Laryngology and Otology, 57: 677-685. Address for correspondence: Dr. RedaKamel, M.D., Flat 6, 5 Dokky Street, Dokky-12311, Giza, Cairo, Egypt.
